New research: Insurance plan structure can have discriminatory effect

New research from the Harvard University Center for Health Law and Policy Innovation (CHLPI) is another piece of evidence showing how health insurance plan design may be trying to discourage enrollment by patients with certain conditions and also preventing some individuals from actually getting care.

CHLPI looked at trends in state health insurance exchange plans over several years and reports they are “increasingly alarmed by lower rates of coverage for necessary HIV and HCV [hepatitis c] treatment regimens.” At the same time, cost sharing for those treatment regimens, even if the plan covers them, is increasing. They note, “This insurance practice has the discriminatory effect of discouraging individuals in need of specific medications from enrolling in these plans or of shifting the burden of the cost back to these enrollees.” For example, the Harvard researchers found in 2016 some insurers are requiring coinsurance of 40 percent or more for all hepatitis c medicines; this high coinsurance is also sometimes required for most or all HIV medicines.

We’ve talked about this before here, here and here on AccessBetterCoverage.org. This is yet another example of why addressing market distortions that create perverse incentives for insurance plans to prevent patients who need certain medicines from enrolling is necessary.

One change to help address this problem is to improve the risk adjuster used in the individual and small group markets, including for the health plans in the new marketplaces created by the Affordable Care Act. Improving risk adjustment by including data on whether beneficiaries are using certain classes of medicines could better compensate plans for taking on higher risk patients, allowing these plans to focus on helping patients manage their chronic conditions and avoid costly complications. The Administration’s interest in thoughtfully examining the current risk adjuster and how it could be improved is an important first step to move policies forward that benefit patients.

Karyn Schwartz Karyn Schwartz is a deputy vice president in the policy and research department at PhRMA, where she has responsibilities for policies related to the Affordable Care Act, Medicaid and the 340B program. Prior to joining PhRMA, she worked at the Department of Health and Human Services and the Kaiser Family Foundation. When not immersed in arcane policy details, Karyn enjoys going for early morning runs and exploring Washington, D.C. with her twin boys.